I looked at my geriatric clinic schedule recently and saw the reason for the visit, “Angry Outburst.”  The clinic nurse explained that this hard-of-hearing resident in his 90s doesn’t hear our medical assistants when they knock on the door to announce their visit for medication administration, so they use their pass card to enter.  In recent times he has become very angry when he discovers them in their apartment.  The prior day, the MA was so frightened that she left and didn’t pass his medicines.  I asked the clinic nurse what she thought should happen next.  She wondered if I could prescribe a medicine that might reduce his anger so they could pass the meds and he could stay in his apartment.  In response, I asked her: if your eight-year-old child had a problem with anger management, would you ask his physician for a medicine to reduce the severity of the problem?  Of course, she said “no.”  

When I then saw this very old and medically complex patient, within the first 30 seconds it was clear he didn’t understand a word I had said.  When I removed my mask, he could understand me and was able to address questions about social isolation, sadness, and reduced pleasure.  I called his daughter who lives out of state and she agreed that he might have depression expressed in his anger episodes.  She also said her father had given up on his hearing aids, since he could no longer get them to work (change batteries on schedule d/t dementia).  Armed with my assessment and his input, we modified the care plan to have the clinic take over management of his hearing aids, to visit without a mask on, and to work with our activities program to address his isolation.  Since depression might be present and contributing to his episodic anger expression, we agreed to a trial of an antidepressant starting at a low dose.  

I recently wrote a wave article on the CMS initiative to identify and penalize facilities with misdiagnosis of schizophrenia.  As noted in that article, the OIG study on the use of psychotropic meds in long-stay residents with dementia (November 2022) found a significant increase in the diagnosis of schizophrenia in residents with dementia and a large increase in the use of anticonvulsant medicines like the gabapentanoids or divalproex (Depakote), even though a 2018 Cochrane review (https://www.cochrane.org/CD003945/DEMENTIA_valproate-preparations-treatment-agitated-behaviour-people-dementia) of this medicine had concluded that this medicine was possibly harmful and lacked evidence of benefit.  Is the off label increased use of Depakote for its sedating effect another example of ageism that would not occur in the care of our youth?

Our California Partnership to Improve Dementia Care recommends we move away from the term BPSD (Behavioral and Psychiatric Symptoms of Dementia) to embrace BPED, (Behavioral and Psychiatric Expressions of Dementia) since this is a common problem in persons with dementia, and isn’t always a “symptom,” but more often is an expression of unmet needs.  When we frame the problem this way, it’s our job to do a deep dive investigation of the expression. Attempting to find root causes not only can reduce the likelihood of similar expressions, but also better address the needs of our residents and provide care that matters to them.  In the process of doing this sometimes labor-intensive work, we may find that our facility care processes can be adjusted to prevent similar expressions in other residents with dementia.  At this time, our State Partnership is looking for facilities willing to pilot a tool we have developed to help facilities identify and address potential unmet needs. If you are interested in being a part of this Pilot project, please email me. 

Is it time for your frontline professionals to view BPED as an opportunity to improve the care they provide, rather than a behavior to first be managed with a psychotropic med?  The partnerships completed resources are available on the Leading Age website at: https://www.leadingageca.org/ca-partnership-for-improved-dementia-care

Tim Gieseke, MD, CMD

[email protected]